Suwannee Democrat

Local News

November 14, 2013

Navigating the marketplace

Mayo — Health Insurance Marketplace Navigator Representative Tracy Tygrest, who handles Lafayette and Suwannee counties, offered an overview of what to expect with the Affordable Care Act (ACA).

Rich Wisdahl from Lafayette Health Care Center invited Tygrest to speak at a local meeting after receiving an e-mail about an available speaker in the area who could help explain the new healthcare program. Tygrest is originally from Tennessee and now lives in Wellborn.

“I thought that would be interesting to me,” said Wisdahl. “I would really like to get more information just like anyone in this audience today. I don’t know anything other than all the hoopla and seeing e-mails and stuff like that, which most likely had nothing to do with anything, other than someone’s opinion.”

“If I can interrupt, I’m just going to give you more hoopla,” said Tygrest, grinning.

Wisdahl said his opinion of the ACA is that it isn’t going to be perfect because it is a politically negotiated system.

“Will it do what I would like it to do, as far as driving down costs?” he asked. “No, not immediately. Will it restrain costs in the future? I think the answer will be yes.”

Wisdahl said he employs a little over 100 people and only about 6-10 of them have real health insurance. For years, he said, he has been fighting a battle to provide affordable health coverage for his employees. With the ACA, Wisdahl said he thinks there will be some who will be pleased and some who won’t be pleased with the rates.

Tygrest, who is employed by Suwannee River Area Health Education Center, explained that the ACA is a combination of the Patient Protection and Affordable Care Act, and the Healthcare and Education Reconciliation Act of March, 2010. Enrollment began Oct. 1, this year and it entitles everyone to have an affordable, quality health plan.

Health insurance plans

Tygrest said within the ACA there are four tiers of quality health plans; bronze, which pays an average of 60 percent of healthcare costs, silver, on average about 70 percent, gold with an average of 80 percent, and platinum, which pays on average about 90 percent.

The higher percentages mean higher monthly premiums, but lower copays, deductibles and/or co-insurance. Acceptable Marketplace insurance plans will include doctor visits, hospitalization, maternity and newborn care, mental health and substance abuse services, prescription medications, rehabilitation services and equipment, laboratory costs, preventive/wellness services, and pediatric services. Pediatric services include dental and vision, but adult dental and vision has to be purchased separately. Medicaid will also offer these services next year.

As with the old style health insurance there are variations in types of plans, such as HMO, PPO POS, which is Point of Service where you must stay in the network and need a referral, and FFS, which is Fee for Service, the least restrictive and most open access to medical care, but it is the most expensive.

Why the ACA?

Tygrest said the reason for the ACA is that according to the U.S. Census Bureau and other government websites, the U.S. population of legal citizens in 2013 is 316 million, and in 2011, 48 million people (about 15 percent) were uninsured. Costs incurred due to those uninsured in 2011 was $41 billion.

“The government felt like in order to offset that, we need to try to offer insurance and then penalize people who choose not to take insurance,” said Tygrest.

For people who use the emergency room for their primary care, Tygrest said, they are running up the costs for people who have insurance.

Most everyone in the audience raised their hand when asked by Tygrest if they had health insurance.

“You guys are lucky,” she said. “We’re not offered insurance in this job.”

Tygrest went over the numerous reasons why so many are uninsured, such as lack of availability of coverage or services, lack of financial resources, misperceptions of medical needs because of a sense of being in good health, as well as personal beliefs.

When one applies for insurance in the Marketplace, Tygrest said, first of all, they cannot be turned down due to pre-existing conditions. The applicant will be advised whether or not they qualify for Medicaid, Florida KidCare, and any subsidies, as well as matching you to insurance plans based on your needs and wants.


The enrollment period was to initially run from Oct. 1 through March 31, 2014, however it was extended for another six weeks due to glitches in the system, Tygrest explained. If you enroll by Dec. 15 and your premium is paid, your insurance coverage will begin Jan. 1, 2014. If you pay your premium between Dec. 16-31, your coverage will start the first day of the second month. For example, if you enrolled on Feb. 19 and paid your premium that day, then your coverage would start on April 1.

If you currently have a health insurance policy that offers the government mandated standards of a quality health plan that provides the minimum essential health benefits, Tygrest said you can keep that plan. You must also have insurance for yourself and your dependents based on your last tax return.

Farm Bureau Insurance agent Lance Braswell said he was told the subsidies were based on an estimate of a person’s 2014 income, but Tygrest said it is based on that person’s 2012 tax return. When Braswell asked Tygrest some questions about the online application process, she said she hadn’t been able to access it, so she couldn’t give him an answer.

Many in the audience were concerned about how the ACA determines one’s poverty level, because many people have no income, but do have extensive property assets.

Tygrest said, “They’re looking at your income, not your value.”

There are four ways to apply for health insurance; with a Navigator, by calling 800-318-2596, by mail to Health Insurance Marketplace, 1005 XYZ Drive, Washington, D.C. 20005, or online at

The website, Tygrest said, has an estimator that can give consumers an overview of the plans and their costs. 

Penalties and Exemptions

Penalties for those who don’t enroll are $95 per adult or one percent of your income, as well as $47.50 per child with a maximum of $285 for 2014. In 2015, the penalty goes up to $325 per adult or 2 percent of your earnings, in 2016 it goes up to $695 or 2.5 percent, whichever is greater. After that the penalties will be based on inflation.

There is a list of exemptions for people, such as those who are incarcerated, certain Indian tribes, hardships and such, Tygrest said.

Wisdahl interjected that in the future, he sees a change coming, especially for emergency room care, whereby people would have to prove they have insurance or a means to pay prior to being treated.

“It’s a cold thing,” he said. “But it’s coming.”

Tygrest compared health insurance to auto insurance.

“You don’t think you’re going to need it, you hope you never need it, but you keep it just in case,” she said.

At the end of 2014, Tygrest said notices will go out to those who have enrolled and at that time they can make any changes for the next year. The next open enrollment will begin in Jan. 2015.


A discussion ensued about Medicaid and the fact a lot of people are selling off their assets, especially older people, in order to qualify for Medicaid because you can’t have over $2,000 in assets. Another issue arose concerning those who have not filed income tax in years or have never filed at all. Tygrest admitted that some things aren’t being addressed in the ACA.


There were not any major changes to Medicare, other than prohibiting discrimination due to pre-existing conditions, eliminating annual limits for essential health benefits, offering tax credits, and possibly buying Marketplace insurance instead of Medicare Part A, along with the possibility of qualifying for prescription discount programs.


Illegal aliens, Tygrest said, do not qualify for health insurance, but their children do. She added that illegal aliens will not be deported and are encouraged to apply for insurance for their children, which they will have to pay for just like everyone else.

Tobacco users

Tobacco users, Tygrest said, will be charged higher premiums than non-tobacco users. She couldn’t give an answer on how much higher those premiums would be as it wasn’t part of her training.

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